CATHOLIC DAUGHTERS OF THE AMERICAS COURT #2278 BINGO_REDACTED.PDF

:

C

q \pplication for Bingo License Packet includes:
e Arizona Form 833 — Application for Bingo License
' Arizona Form 830 — Affidavit

ae Arizona Form 832 —
Endorsement by Local Governing Body

It is advisable that you obtain and review a copy of the
Arizona Revised Statutes on “Games of Bingo” and the
Administrative Ruies prior to initiating an application.
These documents outline qualifications and requirements
for obtaining a bingo iicense and may be obtained from:

* www.azleg.gov/ and
* www.azsos.gov/public_services/able_of_contents.htm

All forms must be complete and legible. Please type or
print using black ink only. Forms are available in a fillable
pdf format at Arizona Department of Revenue (ADOR)
web site www.azdor.gov. Be sure to include on your
application a telephone number where you (or another
party responsible for the games) can be reached during
the day.

The bingo license package for new license and appropriate
fees must be sent to and approved by the local governing
body (the city council for incorporated cities or the county
board of supervisors for unincorporated areas) prior
to submission to the ADOR Bingo Section. Upon their
approval or disapproval, the local governing body will
forward the license package to the ADOR Bingo Section.

Endorsement By Local Governing Body Form

Complete lines 2, 3, and 4 of Arizona Form 832,
Endorsement by Local Governing Body and submit to
your loca! governing body with the bingo license package.
A bingo license cannot be issued until this form is
received by the ADOR Bingo Section.

As part of the review of your application for a bingo license,

the ADOR Bingo Section will conduct an analysis of

any purchase agreement for either equipment and
or_real property to determine that such agreement
is bona fide. This analysis is conducted pursuant to
A.R.S, 5-406.F. The Bingo Section does not “approve”
these agreements as to content or other legal ramifications.
You are strongly advised to consult with independent legal
counsel to determine your rights and obligations under
these agreements.

If you need additional forms or have any questions, please
call the ADOR Bingo Section in Phoenix at (602) 716-7801.

Arizona Department of Revenue Application for Bingo License Packet

CHECKLIST:

Send copies of all documents listed below unless otherwise
noted. Before mailing, check to make sure that you have
included the following:

4£] Original completed Application for Bingo License
(Arizona Form 833),

210 Original completed affidavits (Arizona Form 830).
Class B and Class C applicants must include a
completed affidavit for each person participating
in the conduct of your games. Class A applicants
must include a complete affidavit for each person
participating as a manager, proceeds coordinator
and supervisors.

31 Renta! agreement if more than one licensee is using
the same rented premises in which to hold bingo.

4(] Application for Special Bonus Game (Arizona Form
831) available at www.azdor.gov. If you do not
conduct special bonus games do not complete the

plication.
5LY License fee payable to the Arizona Department of
Revenue:
License Type Fee
Class A $10,007
Class B $50.00

$200.00

Class C
6k.¥ The local governing body fee will be payable to the
appropriate local governing entity:

License Type Fee
Class A < $5.00»
Class B $25.00
Class C $50.00

7] If applying as a qualified organization, a current
membership fist must be submitted and must
indicate initial membership dates for all members
of the applicant organization. Any person from any
branch of the applicant who will be participating in the
operation of bingo games must be included on the
membership list.

a If applying as a qualified organization, the following
must be submitted: charter documents, articles
of incorporation, corporate bylaws, articles of
association, minutes of the establishment meeting,
and minutes of meetings for two years (two months of
each year) immediately prior to the date of application
for the applicant, parent and auxiliary.

91] Purchase agreement for real property (where
applicable).

10L] Purchase agreementbill of sale for bingo equipment
and supplies.

11(1 Original local governing body endorsement.

ADOR 10331 (2/20)

A ie COURT OUR LADY OF LOURDES NO. 2278
Cae) CATHOLIC DAUGHTERS OF THE AMERICAS

SUN CITY WEST, ARIZONA

MW
February 17, 2025 R EC EIVED

FEB 2 4, 2025
Maricopa County Clerk of the Board MARICOPA COUNTY ,
301 W Jefferson Street, 10"" floor CLERK BOARD OF SUPERVISOR

Phoenix, AZ 85003
Dear Board

The Catholic Daughters of the Americas at Our Lady of Lourdes Catholic Church, Court #2278,

wouid iike io requesi a Bingo License irom ihe Siaie of Arizona. We were ioid in order io play
Bingo within our membership, we had to apply for a license; we want to do what is correct.

We are a small court and were given all the tools to start a Ringa game. Currently, we do not
have to purchase anything. We have a Bingo Cage; we will hand roll the bingo balls, and we will
have sumeoue call out the numbers aud a verifier to make sure the correct number is called.
Someone donated Dabbers, Bingo papers, and all supplies needed to start the Game. We have
been told to use Cactus Supply house when we need new supplies.

This game would be open only one day a month from 12-3 p.m., and we have been allowed to use
our multipurpose room off the church for the game. Any money we charge to play the game is
given back to the player who wins that game. This will be open to the members of our court and
the parish of the church.

I hope the forms included in this letter have been completed to your satisfaction as stated in the

ules of the AZ Depuitmeni of Reventic. Any Questions you imay have, please contact ine at aiiy
time —_—— You may email me a Thank you for your

assistance in our new venture.

boro Thi 6 bey (ehwenec,

Judy Penman, Vice Regent

queaion 4 F

Sincerely yours

63) New Application

Arizona Form 832

Endorsement by Local Governing Body

Bingo

FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A
e License Applicants: Complete lines 2, 3, and 4, Submit with entire license package to local governing body.
e Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section.

ARIS. §§ 5-409 and'5-410

(1 Change of Location

Date

2h olan

License Number

From (Name of local governing body)
MARICOPA CO CLERK OF THE BOARD

Address (number and street, PO Box)
‘(307 'W JEFFERSON ST 76TH FLOOR

City
PHOENIX

State

ZIP Code
85003

Phone No. (with area code)

(692-746-7801 (pv -S0b-S) Uv

REVENUE USE ONLY. DO NOT MARK IN THIS AREA,

fey PM

RCVD

1 This is to certify that ont a hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
T] Application for a bingo license by the following applicant.
0 Application for a bingo license location transfer.

2 Applicant's Name

CATHOLIC DAUGHTERS OF THE AMERICAS COURT #2278

3 Location/Address where live bingo willbe conducted: |City State {ZIP Code
19002 WN IZ8TH AVE ‘(SUN ‘CITY WEST YAZ 185375
4 Fillin the time on the days tive bingo will be played:
SUN MON TUE WED THUR FRI SAT
Clam. Olam. Olam. Olam. Elam. Olam Da.
‘Yt pam. L p.m. L psn. u ‘Opi: fl 12.3 p.m: L Cp: f Jp:

5 Who is your live bingo supplier?
CACTUS BINGO SUPPLY

6 Recommendation for the application: [J Approved [] Disapproved

7 Specific reasons for disapproval are hereby listed pursuant to A.R.S. § 5-404.1:

This endorsement must be signed by a delegated authority of the local governing body.

PRINTED NAME

SIGNATURE DATE TITLE

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

“EE (602) 716-7801

ADOR 10326 (2/20)

Arizona Form 833 _

Application for Bingo License

* Type or print in black ink and complete all information requested on this form. If you do not, your application will be returned. All
information is subject to verification. If you need more space, attach additional sheets.

* All bingo licenses expire one year from the date of issue. To continue conducting live bingo games, you must renew your license
t to ARS, §§ §-403(C) and 5-410,

prior to the expiration date pursuan

1 Applicant's Name

CATHOLIC DAUGHTERS OF THE AMERICA'S COURT #2278

Falsification of information
contained in this application

2a Mailing Address
19002 N 128TH AVE

constitutes a Class 6 felony.

2b City State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
SUN CITY WEST AZ 65375 Has

3a Administrative Office Location
SAME AS ABOVE

3b City State ZIP Code

4a Name of Contact Person

SUBYPENMAN

4b Telephone No.
rn PM RCVD

5 Class B and Class C license applicants only: if applying as a qualified organization, check one box to indicate the type of

organization:
C1 Charitable
(1 Fraternal

O Socia!

(1 Volunteer Fire Department

(J Religious 1 Veterans
(0 Homeowners Association 1 Nonprofit Ambulance Service

6 Class B and Class C license applicants only applying as a qualified organization, provide parent or auxiliary information:

6a Parent Name

6b Auxiliary Name

Address — Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt., Apt. No,

City

State ZIP Code

City State ZIP Code

lion:

7 Class B and Class C license applicants only applying as a

qualified organization, list the current officers or Board of

7a Name

7b Name

Title

Title

. Address — Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural Rt, Apt. No.

City State ZIP Code City State ZIP Code
7c Name 7d Name
[Title | Title

Address ~ Number and Street, Rural Rt., Apt. No.

Address — Number and Street, Rural RE, Apt. No.

City

State ZIP Code

City State ZIP Cade

8 Class B and Class C license applicants only: Bingo checking account information:

Checking Account Number

Bank Name

Bank Branch

Continued on page 2>

ADOR 10334 (2/20)

9

10

4

12

13

14

15

16

nts Name (as shown on page T}

2 ~ APPLICATION FOR BINGO LICENSE
Class B and Class C license applicants only: Bingo interest-bearing account information:
Account Number Bank Name Bank Branch

Class B and Class C license applicants only: List all officers and/or supervisors authorized to sign checks from the accounts
listed above. if applying as a qualified organization, all supervisors must be members of the applicant:

= Saeki Mialki ‘Garcture. Chen
Tite

List the name(s) of the one or two persons who will serve as," vanagers. {f applying ac a qualified crganization, thecs porsuis
must be members of the applicant. Each person must submit an affidavit.

dia Name 1ib Name
Dono hy Alercmmace

Title Title

| Manages. Mowag 2A.

List the name of the one person designated as proceeds coordinator. If applying as a qualified organization, this person must be
an officer or director and a member of the applicant. Each person must submit an affidavit.

“A Title . Crna .

List the name(s) of the person(s) who will serve as supervisor. Hf applying as @ qualified organization, each person must be a
member of the applicant. Each person must submit an affidavit. If additional names are required, please attach affidavits.

. Name . ' Aa . k yk .

List the name(s) of the person(s) who will serve as assistants. If applying as a qualified organization, each person must be a
member or new member of the applicant. Except for “Class A” licensees, each person must submit an affidavit.

14a 44b N;
Uae Kie M0 Al&A ™

44c Name 14d Name

Street address of the Doe location where live bingo will be played:

Games of Bingo must not exceed 5 days a week. Indicate the time on each respective day that live bingo will be played:
SUN MON TUE WED THUR FRI SAT.

Cam. Olam. Oa.m, Olam, Dam. Clam. Clam.

t p.m.h sEIp.m. he E)p.m.f. Dpm (4-3 Eb... p.m. p.m,

Continued on page 3 >

ADOR 10334 (2/26) Arizona Form 833 Page 2 of 5

Applicant's Name (as shown on page 1)

CATHOLIC DAUGHTERS OF THE AMERICA'S COURT #2278

APPLICATION FOR BINGO LICENSE

17 Indicate the type of premises where bingo will be played. Check one box:

a (& Welther rent nor morigage willbe paid from ‘bingo junds.

b ["} Rented or leased. Aftach rental affidavit and copy of rental agreement.

Landlord's Name

NIA

Address — Number and Street, Rural Rt, Apt. No,

Telephone Number (with area code)

City State ZIP Code

c (J Owned solely by the organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document.

Holder of Mortgage
NIA

Address — Number and Street, Rural Rt, Apt. No.

Telephone Number (with area code)

City State ZIP Code

d (J Owned jointly with other organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document:
1) Hoider of Mortgage Address — Number and Street, Rural Rt., Apt. No.
N/A

Telephone Number (wilh area code) City State ZIP Code
2) Co-Owner Holder: Address — Number and Street, Rural Rt, Apt. No.
Telephone Number (with area code) City State ZIP Code
3) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code

18 List bingo licensees who are or will be conducting bingo in the same premises as you and those licensees located within 1,000

feet of your premises:

18a Name 18b Name
N/A NIA
Address — Number and Street, Rural Rt., Apt. No. Address ~ Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
Continued on page 4 >
ADOR 10334 (2/20) Arizona Form 833 Page 3 of 5

‘Applicant's Name (as shown on page 1)

CATHOLIC DAUGHTERS OF THE AMERICA’S COURT #2278

D
19 Expected bingo expenses: Beat Kewus

APPLICATION FOR BINGO LICENSE

a ‘Mortgage: Soper monith
Payable to Address — Number and Street, Rural Rt., Apt. No.
N/A
Telephone number (with area code) City

State ZIP Code

b Rent: our (J occasion
Payable to

Address — Number and Street, Rural Rt., Apt. No.
N/A
Telephone number (with area code)

S$, per month Oh

City State ZIP Code

ec Janitorial Services: $, ; perf) month [hour © occasion
Payable to

Address — Number and Street, Rural Rt, Apt. No.
N/A
Telephone number (with area code)

City State ZIP Code

d Accounting Services: §, per{Jmonth CJ hour [J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
NIA
Telephone number (with area code)

City State ZIP Code

e Security Services:  $, per month CJhour (7 occasion
Payable to

Address — Number and Street, Rural Rt, Apt. No.
N/A

Telephone number (with area code) City State ZIP Code
f Bingo Supplies: $ ; per

Payable to Address — Number and Street, Rural Rt., Apt. No.

CACTUS BINGO SUPPLY 3210 E ROSSER RD STE 15

Telephone number (with area code) City State ZIP Code

602) 268-2848 PHOENIX AZ 85004

20 Who is your live bingo supplier? (For all bingo supplies). Do you foresee purchasing/renting machines as “technological aids for
your live bingo games?

N/A HAVE NOT PURCHASED YET NO PURCHASING ANY SUPPLIES

Continued on page 5 >

ADOR 10334 (2/20)

Arizona Form 833 Page 4 of 5

Applicant's Name (as shown on page 1)
CATHOLIC DAUGHTERS OF THE AMERICA'S COURT #2278 APPLICATION FOR BINGO LICENSE

1, JUDY PENMAN under penalty of perjury and upon oath, declare that | am duly authorized to sign
| and file this application. I hereby swear or confirm that I have read the foregoing application and know the contents thereof and that
all information proyided has been fully, accurately, and truthfully completed to the best of my knowledge.

VICE REGENT CATHOLIC DAUGHTERS #2278
y THLE

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

®B (602) 716-7801

REVENUE USE ONLY, DO NOT MARK IN THIS AREA.

[J Approved (I Disapproved (JClassALicense ([JClass B License {JClass C License

Reviewer's Name (please print) Date License Number Effective Date Expiration Date

ADOR 10334 (2/20) Arizona Form 833 Page 6 of 5

Arizona Form
830

Affidavit

Bingo

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information fs blank or Incorrect, the
affidavit will be returned to you. Ail information Is subject to verification. Disdosure of your Social Security Number (SSN) is voluntary. This information
may be used to estabiish positive Identification for purposes of criminal background checks pursuant to A.R.S, § 5-404... <<"

Position (check the approprigte boxes):
[1 Manager KL supervisor [1] Proceed Coordinator [7] Assistant
7

License Number

ian" USE ONLY. DO NOT MARK IN THIS AREA.
88

t's Nam,
-t

‘ocial Security Number

Nia

PM RCVD

if licensee Is a qualified organization, complete the following section:

Member? Date Joined Organization
IextYes [INo hows
Officers? Officer Title

(1 Yes “BENo

Do you have an affidavit on file for any other licensee?
[O Yes__BKNo If “Yes”, list iconse number(s):

knowledge.

the above-named affiant, under penalty of perjury, upon oath, depose
and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised
Statutes, Title 5, Chapter 4, and the rules of the licensing authority. [ am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. | hereby swear or confirm that | have read

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

Whe.

ignature of Affiant

Lae

Date

BS;

Please malt to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

@ (602) 716-7801

ADOR 10327 (2/20) Print Form |

Arizona Form

830 Affidavit Bingo

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo, If any information Is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive Identification for purposes of criminal background checks pursuant to A.R.S, § 5-404,

Licensee’s Name

CATHOLIC DAUGHTERS OF THE AMERICAS COURT #2278
Position (check the appropriate boxes):

License Number

(2) Manager _[] Supervisor_[7] Proceed Coordinator [2] Assistant REVENUE USE ONLY, DO NOT MARK IN THIS AREA.

Affiant's Name
KAREN CZAPLEWSKI

Address

ley] PM RCVD

If licensee is a qualified organization, complete the following section:

Member? Date Joined Organization
&yYes [CINo 20214

Officers? Officer Tile

Oyes  BINo

Do you have an affidavil on file for any other licensee?
ClYes No _ If “Yes", list license number(s):

1, KAREN CZAPLEWSKI

AFFIANT'S NAME
and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised

, the above-named affiant, under penalty of perjury, upon oath, depose

Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony, I have not and shail not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. T hereby swear or confirm that T have read

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

Lo capeleewete)

Signature of Affiant “ee

442 ax

knowledge.

Date

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

® (602) 716-7801

ADOR 10327 (2/20)

Arizona Form

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disdosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive Identification for purposes of criminal background checks pursuant to A.R.S. § 5-404. —

Li e's Name | P a License Number
t
x

Position (check the appropriate hOxes):
(1 Manager Oo Supervisor oO Proceed Coordinator BXAssistant fe USE ONLY. DO NOT MARK IN THIS AREA.
88}

Affiant's Name

JaeKie Mial Ke

a

PM RCVD

If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization

IBXYes [I No it OR
Officers? Offigey Title
Va Yes [No 12 Gen “i

Do you < an, gs on file for any other licensee? = /

O Yes lo _If “Yes”, list license number(s):
z

(M Task ie lm: wl Ry , the above-named affiant, under penalty of perjury, upon oath, depose

AFFIANT'S NAME
and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised

Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that I have read
and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

knowledge.

appease

Al 2/ a5.

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

® (602) 716-7801

ADOR 10327 (2/20) Print Form

Date

Arizona Form
830

Affidavit

Bingo

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disdosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

JeXManager (1 Supervisor [2] Proceed Coordinator KL Assistant

Ligensee’s Name License Number
. . ° ed
s
Position (check the appropriatgoxes):

(es) USE ONLY. DO NOT MARK IN THIS AREA.
88}

|Affiant's Name

If licensee is a qualified organization, complete the following section:

PM RCVD

lepaber? Date Joined Organization
Yes [No aA 220
Officers? r Title Vi
Yes [No Vib a geal

Do you have an affidavit on file for any other licensee?

DlYes BK No _ If "Yes", list license number(s):

knowledge.

of

| ae 2 Jit 7] Y / Cdn dad , the above-named affiant, under penalty of perjury, upon oath, depose

and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised
Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that I have read

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

Virb

Date a ie

Please mail to:
Arizona Department of Revenue

Phoenix, AZ 85007

1600 W Monroe Street, Division Code 22

B (602) 716-7801

ADOR 10327 (2/20) | Print Form |

Arizona Form
830 Affidavit

This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information Is blank or incorrect, the
affidavit will be retumed to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

i Lit Numbe:
Lit e's lame . t icense Nu r

Bingo

Position (check the appropriate Boxes):
Manager Supervisor Proceed Coordinator Assistant ea) USE ONLY. DO NOT MARK IN THIS AREA.

Affignt’s Name
/ Ie,
Social Security Number

fei] PM RCVD

If licensee is a qualified organization, complete the following section:

Member? Date Joined Organization
lbd’Yes [J No Zd20
Officers? Officer Title Ke ap Be
pres [No a cae Prey ‘fl

Do you have an affidavit on file for any other licensee?
Llyes No _If"Yes’, list license number(s):
ofthe

I, fl Nor, ut hy ft [ exen de v , the above-named affiant, under penalty of perjury, upon oath, depose

+—AFFIANT'S NAME
and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised

Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that I have read
and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my
knowledge.

Alan. OL ander

Signature ofAffiant 7

Anas

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

® (602) 716-7801

ADOR 10327 (2/20) Print Form |

Arizona Form
830

‘This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to A.R.S. § 5-404.

Affidavit Bingo

Licgnsee’s Name , ia a Number
z
Position (check the appropriate b6xes):
Manager Supervisor roceed Coordinator [7] Assistant VENUE USE ONLY. DO NOT MARK IN THIS AREA.
88)

FMRLS
Social Security Number

[80] RCVD

Member? Date Jgined Organization

Yes [No 1s, &3
Officers? Officer Titfe
Sf'Yes [I No LORS dC,
Do you have an affidavit on file for any other licensee?

Ye “Yes”, i A
O Yes SiN If “Yes”, list license number(s)

iff a Heist E Ch E w/ , the above-named affiant, under penalty of perjury, upon oath, depose

=a ee.

and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised
Statutes, Title 5, Chapter 4, and the rules of the licensing authority. [ am of good moral character and have never been convicted of
any misdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that | have read

and understand the foregoing and verify that the information and statements made herein are true and correct to the best of my

SO

Signature of Affiant

Alta | 46.

knowledge.

Date

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

® (602) 716-7801

ADOR 10327 (2/20) Print Form |

Arizona Form 831 Application for Special Bonus Game Bingo

¢ Type or print in black ink and complete all information requested on this form. If you do not, your application will be returned. All

information is subject to verification.

¢ All approvals to conduct special bonus games expire at the end of each licensing period and must be renewed prior to that time to allow the

continuance of special bonus games.

] [License Number (if known)

Address

LIC0O2. WA p F4 Lo Ave eave USE ONLY. DO NOT MARK IN THIS AREA.

Bz ¢ N42 |05326

Rye Phone NO. (with area code)

Ll 165-2220

PM RCVD

4 When will special bonus games be played? Fill in the time on the days games will be played:

SUN MON TUE WED THUR FRI SAT
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2 Pattern required to accomplish bingo: Loves - AY
3 Number of calls within which a bingo must be accomplished... NAc yy as

4 Amount of designated prize: Spl) ~|5 Type of card to be used:
$, r |_ Daable let cow

6 Cost of card to player: 7 Game nymbeér:
$2-66

8 How much of the $12,000 prize amount available in the quarter will be guaranteed, if any?. A fh

9 Total prize amount offered per quarter. Défearmiecets. By. CAaas.. Risekush > ae $

Describe how the special bonus game program will be conducted:

ice Kie. ly fA ji Ki klugy teva under penalty of perjury, upon oath, depose and say that I am duly
IE

AFFIANTS
authorized to sign and file this “fplicatién, I hereby swear or confirm that I have read the foregoing application and verify that all

and complete to the best of my knowledge.

ha 2S)7-BE

Date

Hi Pi@ase mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
® (602) 716-7801

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

(J Approved (J Disapproved (1 Class B License (J Class C License

Reviewer's Name (please print) Date Effective Date Expiration Date

ADOR 10600 (1/14)
Previous 71-5411 (6/07)